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The target audience for this video is any provider who is likely to experience patient death. We have demonstrated this method to medical students, residents, and faculty and across departments and disciplines of health care including physician assistants and nurses. Emergency medicine (EM) physicians frequently encounter patient death, requiring effective coping strategies. Brief mindfulness practices, including focused breathing, can promote emotional regulation and reduce perceived stress. These techniques are particularly relevant in acute care settings where rapid cognitive and emotional transitions are required.1 While techniques such as "The Pause"-a moment of silence after death-have been proposed, their impact remains understudied. 2-4 In addition to the Pause Method, many physicians at our institution utilize the "Three-Breath Guided Meditation" technique, a structured deep-breathing exercise designed to help reduce stress. This study aimed to assess EM physicians' perceived ability to process patient death, explore coping strategies, and evaluate the effectiveness of both "The Pause" and the "Three-Breath Method." After watching the video, proposed viewers should be able to: 1) describe the Three-Breath technique, and its potential impact on healthcare providers' ability to manage stress and process patient death, 2) evaluate the effectiveness of the Three-Breath guided meditation in improving emotional reconciliation and reducing stress for emergency medicine physicians, and 3) demonstrate the Three-Breath technique and implement it into their own practice. Emergency medicine residents and faculty were invited via email to watch a 4-minute instructional video on the Three-Breath Technique. This video lecture was made available asynchronously, and participants were encouraged to watch the video at a time that was suitable to them. Emergency medicine residents and attending physicians completed a mixed-methods questionnaire on their coping abilities after patient death. The survey included baseline experiences, coping practices, comfort levels, and the 4-minute instructional video. Responses were analyzed using descriptive statistics, Spearman's correlation for continuous variables, and thematic analysis of free-text data. Of 79 invited EM physicians, 49 responded (62%), including 39% attendings and 61% residents (median age 33.5 years, 53% male, 47% female). A weak correlation was found between training level and perceived ability to process death (r=0.27), with attending physicians reporting greater comfort (mean = 4.45) than residents (mean = 3.75). Perceived ability to process death moderately correlated with comfort returning to work (r=0.55). Overall, 59% used the Pause or Three-Breath techniques, and 94% reported comfort coping after patient death. Physicians' comfort in processing patient death increases with training level, with attendings feeling more prepared than residents. Most providers use the Pause1-3 or Three-Breath Method and report comfort in coping. However, the study's single-institution scope, modest sample size, and reliance on self-reported data may limit generalizability. Future efforts should be expanded to additional specialties and emphasize flexibility and individualized strategies to support emotional well-being in clinical practice.The Three-Breath guided meditation technique, as an extension of The Pause,2-4 is being widely adopted by physicians at one US academic institution and may enhance physicians' ability to process patient death, promoting emotional reconciliation and stress reduction in high-pressure healthcare environments. Physician coping with patient death, coping strategies, novel coping strategy, emotional resilience.

To date, traditional primary care practices are often organized around the capacities of one or more physicians. New models of primary care practices involving other health professionals such as advanced practice nurses (APNs) require modified triage models for more adequate patient allocation. Therefore, a modified triage model was developed, informed by experts and reviewed by stakeholders. A convergent mixed-method design with four phases was employed. The study was conducted in Swiss primary care practices. Readiness for change of health professionals working in these primary care practices was surveyed. Triage was reviewed and modified according to expert recommendations, and its feasibility explored in two Delphi rounds with health professionals and stakeholders. Health professionals in primary care practices were interested in improving access to care. Observed triage continued to focus primarily on physicians. The modified triage model was viewed to be practicable, offering a potential way to support more systematic allocation of patients to physicians, APNs, and other health professionals depending on the reason for consultation. Drawing on international guidelines on triage in primary care practices, expert opinion on who seeks care in these practices, and review by stakeholders led to a modified triage model to include other health professionals than primary care physicians. This study did not involve patients but focused on triage in primary care practices. Hence, no trial registration was obtained. The number of people growing older and continuing to live at home with chronic and multiple diseases is increasing. However, less physicians operate in primary care practices in the community, thereby limiting necessary access to care. Among the many solutions to counteract these problems, advanced practice nurses (APNs) are installed at primary care practices. To ensure that the best health professional is made available to people with health problems, current triage needs to be modified. For this purpose, a mixed-method study was conducted with Swiss primary care practices employing APNs in Switzerland. Data were collected on interprofessional collaboration and triage in use. Data were collected on interprofessional collaboration and triage in use. Drawing on these results, a modified triage model was developed. Primary care physicians, APN, other health professionals, and stakeholders critically reviewed this modified triage model. The model may help primary care practices consider different health professionals more systematically when responding to patients’ reasons for consultation. Whether this approach improves access, waiting times, workload distribution, or quality of care requires evaluation in future implementation studies.

As part of the Alliance of Dedicated Cancer Centers' Improving Goal-Concordant Care (IGCC) initiative, we developed and delivered virtual communication skills training (CST) series to improve the quality of serious illness communication and goal-concordant care (GCC) targeting hematologists, medical oncologists, and advanced practice providers (APPs). The CST included two live-virtual workshops: (1) communication frameworks for GCC and difficult conversations and (2) advance care planning (ACP), including documentation and billing. Workshops incorporated didactics, interactive case discussions, role-play exercises, and training in electronic health record documentation and ACP billing. Clinician confidence and feedback were assessed via postworkshop evaluations. Patient-reported experience was assessed using the heard and understood (HAU) scale from Press Ganey surveys. Pre-/post-training changes in top-box HAU scores were analyzed via paired t-tests and mixed-effects modeling. Ninety-three clinicians completed the training evaluation for workshop 1, and 98 completed the evaluation for workshop 2. Over 75% of participants rated content as good or outstanding, with strong gains in self-reported confidence in using ACP tools, Physicians Orders for Life-Sustaining Treatment (POLST) forms, billing codes, and the SPIKES protocol to deliver difficult news. Compared with pretraining scores, physicians demonstrated significant improvement in overall patient-reported HAU scores (79.46 v 83.77, P = .002), particularly for patient perception of being HAU (78.04 v 83.27, P = .012). APPs had higher baseline scores than physicians (90.74 v 78.04, P < .001), with no significant change post-training. Our IGCC CST series improved clinician-reported confidence in applying the learned skills and enhanced patient-reported communication quality among physicians, supporting broader implementation of the training program to strengthen serious illness communication in oncology care.

Nationwide trends from 2018 to 2022 demonstrated rising pediatric mental health diagnoses amidst a specialist shortage, shifting care to primary care settings. Specific trends among patients seen by family physicians in the military health system have not previously been published. This study addresses a research gap by characterizing mental, emotional, neurodevelopmental, and behavioral health (MEDB) care trends provided by family physicians to military dependent children in direct (military treatment facilities) and purchased (civilian) care systems, focusing on preventive visits. A retrospective observational analysis was conducted examining preventive visits (N&#x2009;=&#x2009;193,495) between 2018 and 2022. MEDB diagnoses were grouped into 16 categories based on ICD-10 codes. Descriptive statistics and joinpoint regression analyses assessed changes in diagnosis rates and trends by age group (5-11, 12-17, 18-25 years) and care system. Logistic regression and odds ratios looked at associations between MEDB diagnosis and care system, adjusting for age, sex, and year of diagnosis. Further analyses looked at associations between MEDB diagnosis and care system, adjusting for sex and year of diagnosis and stratified by age. MEDB diagnoses during preventive visits significantly increased (P&#x2009;<&#x2009;.05) in both systems and all age groups between 2018 and 2022. Children aged 5-11 most commonly received neurodevelopmental diagnoses, while anxiety, depressive, and trauma/stress related disorders predominated among adolescents and young adults. The number of preventive visits with multiple MEDB diagnoses nearly doubled in purchased care (2018 N&#x2009;=&#x2009;481; 2022 N&#x2009;=&#x2009;936). In direct care, there was an average quarterly increase in MEDB diagnoses between 7.6% (5- to 11-year olds) and 10.9% (12- to 17-year olds); in purchased care the average quarterly increase was between 6.6% (5- to 11-year olds) and 14.7% (18- to 25-year olds) in MEDB diagnoses. From 2018 to 2022, the percent of preventive visits associated with MEDB diagnoses managed by family physicians significantly increased. These findings emphasize the importance of enhancing behavioral health training and resources for family physicians to optimize military family well-being and support service member readiness.

Global glycemic control in diabetes is suboptimal, with persistent gaps between guideline recommendations and clinical practice. To evaluate the effectiveness of a role-playing-based intensive training program for physicians in improving glycemic control among patients with type 2 diabetes. This was an open-label, 2-arm parallel, cluster randomized clinical trial conducted at 205 centers in China, with enrollment from February 13 to September 19, 2023, and 12-month follow-up completed on October 25, 2024. In phase 1, 205 physicians from qualified diabetes centers across China were enrolled from February 13 to April 29, 2023, and randomly assigned to the intensive training group (n&#x2009;=&#x2009;103) and the regular training group (n&#x2009;=&#x2009;102). In phase 2, 2017 patients with type 2 diabetes were enrolled from February 28 to September 19, 2023. Data were analyzed from January 1 to June 1, 2025. One-week on-site role-playing-based intensive training (involving simulating patient roles in experiencing diabetes-related health examinations, complication scenarios, lifestyle intervention, and face-to-face conversations) vs regular training. The proportion of patients achieving a hemoglobin A1c (HbA1c) level of less than 7.0% at 6 months. The primary analysis was based on the intention-to-treat principle. A total of 205 physicians (mean [SD] age, 36.2 [5.1] years; 155 women [75.6%]) and 2017 patients (mean [SD] age, 53.0 [7.0] years; 713 women [35.3%] and 1304 men [64.7%]) were enrolled, with 1009 patients in the intensive training group and 1008 patients in the regular training group. At 6 months, a significantly greater proportion of patients in the intensive training group achieved an HbA1c level less than 7.0% compared with the regular training group (58.0% [476 of 820] vs 42.9% [351 of 818]), with an adjusted between-group difference of 16.6% (95% CI, 7.2%-25.7%; P&#x2009;<&#x2009;.001). At 12 months, the difference between the intensive training group and the regular training group remained significant (60.9% [502 of 824] vs 44.6% [371 of 832]; adjusted between-group difference, 17.0% [95% CI, 7.0%-26.8%]; P&#x2009;<&#x2009;.001). The intensive group had greater reductions in body mass index (adjusted between-group difference, -0.3 [95% CI, -0.5 to -0.1]), waist circumference (adjusted between-group difference, -1.4 cm [95% CI, -2.1 to -0.8 cm]), fasting glucose (adjusted between-group difference, -6.3 mg/dL [95% CI, -10.7 to -1.9 mg/dL]), and systolic blood pressure (adjusted between-group difference, -1.5 mm Hg [95% CI, -2.9 to -0.1 mm Hg]). Serious adverse events were comparable between groups (intensive group, 2.6% [26 of 1009]; regular group, 2.4% [24 of 1008]). In this cluster randomized clinical trial of role-playing-based intensive training for physicians managing type 2 diabetes, the intervention significantly improved patient glycemic control. These findings suggest a feasible strategy to narrow the guideline-implementation gap in diabetes care. ClinicalTrials.gov Identifier: NCT05715307.

Problem: In Taiwan's hierarchical medical culture, postgraduate year (PGY) physicians face significant workplace challenges, exacerbated by Confucian values of hierarchical deference and collective harmony, which discourage open discussion of power imbalances. Approaches rooted in individualism, such as speaking-up initiatives and direct feedback pedagogies, encounter cultural barriers in this high-power-distance, collectivist context. While digital-native trainees increasingly use medical memes to express workplace frustrations, these community-generated expressions have not been systematically used for structured reflection in hierarchical medical education contexts. Intervention: In this pilot study, we designed a meme-based reflective learning curriculum integrating Kolb's experiential learning cycle, Palmer's "third things" approach, and Sch&#xf6;n's mediating artifacts. Eight PGY physicians completed six monthly 90-minute sessions (January-June 2024), with follow-up interviews conducted six months post-intervention (December 2024). We curated memes from Taiwanese medical social media that depict workplace challenges, including hierarchical powerlessness, interprofessional tensions, emotional regulation, unclear workplace rules, time management, and patient-doctor communication. Sessions guided participants through Kolb's cycle: concrete experience (meme viewing), reflective observation (discussions), abstract conceptualization (consensus-building), and active experimentation (implementation). Context: The study was conducted at a medical center in Taiwan, where PGY physicians, competing for residency positions through an informal but widespread internal recruitment practice, faced intense pressure to maintain favorable impressions among seniors. This precarious status fostered reluctance to voice concerns as they navigated monthly rotations across departments with different cultures and unwritten rules. Impact: Participants demonstrated learning across all Kolb stages. Framed as an untested feasibility, the approach made previously unspeakable experiences discussable, creating resonance as participants recognized shared struggles. They developed practical strategies for emotional regulation and for navigating interprofessional relationships. However, encountering systemic barriers to implementation prompted an unexpected transformation: participants developed critical consciousness, shifting from seeking adaptation strategies to questioning the structures themselves. They articulated, "The problem isn't us. It's the whole unreasonable system," shifting the focus from coping to why this system exists. This evolution, which moves beyond an adaptation-focused curriculum toward Freire's dialogical education, emerged alongside a sense of powerlessness, as participants lacked the authority to enact structural change. Lessons learned: Drawing on Freire's concept of generative words, we theorize that community-generated memes functioned as generative artifacts: culturally embedded materials that fostered both workplace reflection and critical consciousness. This approach reframes Confucian collectivist orientations as empowering resources through what we term "safe subversion," in which humor's incongruity, ambiguity, and collective ownership keep critique within culturally tolerable limits. However, translating consciousness into structural change requires strategic alliances with educators who wield hierarchical authority in service of learning, bridging trainee awareness and institutional reform.

Factors contributing to poor sleep quality among healthcare professionals in the period immediately following the COVID pandemic are incompletely understood. Clinical staff from one tertiary hospital in Haikou, China, were invited in April 2023 via social media groups to complete a 33-item questionnaire comprised of demographic data, factors influencing sleep quality, and the Chinese versions of the Pittsburgh Sleep Quality Index (PSQI), the simplified Generalized Anxiety Disorder Scale (GAD-2), and the simplified Patient Health Questionnaire (PHQ-2). Data were analyzed using descriptive and multiple linear regression statistics. The prevalence of poor sleep quality (PSQI score &#x2265;7) was 55.8% (293/525). Sleep quality was significantly poorer in nurses as compared to physicians and other clinical staff (p=0.001). Staff with higher levels of education reported better sleep quality (p=0.039). Anxiety and depression symptoms were associated with poor sleep quality, prolonged sleep onset, decreased total sleep time, decreased sleep efficiency, sedative-hypnotic use, and daytime functional impairment (p<0.001). Multiple linear regression analysis found independent statistically significant associations between sleep quality and profession type, education level, night shift work, and anxiety and depression symptoms (p<0.05). In the period immediately following the COVID pandemic, nurses were found to have poorer sleep quality than physicians and other hospital clinical staff. Night shift work, lower education level, and anxiety and depressive symptoms demonstrated the largest associations with poor sleep quality. Further research should investigate methods for identifying hospital clinical staff at risk of poor sleep and its consequences and effective preventive and mitigation measures.

This curriculum is designed to prime pre-medical-field undergraduate students with medical research concepts and skills necessary to assist Emergency Medicine (EM) residents on clinical research projects in a community hospital setting. The PRIMER lecture series should run two to three days with six hours of lecture content to be covered. Project completion and poster presentation should take 8-16 weeks depending on time constraints, resources, and project scope. Scholarly research has taken an increasingly prominent role in both undergraduate and graduate medical education. However, researchers and clinician-teachers can be limited in productivity due to lack of funding, time, and formalized infrastructure. This can result in siloed activities, incomplete or unrealized ideas, and often make research challenging for student and resident physicians alike.1 These barriers to participating in scholarly research are further exacerbated for those in community-hospital-based residencies and community- or rural-medicine educational tracks because these facilities have further reduced access to research personnel and resources.2, 3 Simultaneously, research literacy and experience are becoming increasingly critical qualifications for admission to professional medical educational programs.4,5 Developing structured research training and mentorship for premedical students in community hospital settings can simultaneously enhance residents' research capacity and provide premedical students with critical experience and exposure needed for medical school admission. The purpose of this project is to design a didactic training to provide undergraduate research assistants the necessary training to enhance resident research projects in the emergency department. The educational strategies used in this curriculum include: 1) Blended learning of in-person lectures and online readings and resources implemented in a three-day workshop to provide foundational research knowledge, skills, and resources to research assistants before beginning projects, 2) Experiential learning implemented in workshops interspersed through the three-day intensive, allowing students to begin literature searches, compose IRB proposals, and develop data management and analysis plans that apply to their assigned research project, and 3) Group Learning where students develop action plans, communication, and presentation skills. The educational outcomes were quantitatively and qualitatively analyzed by administration of a pre- and post-test and self-evaluation using a 5-item Likert scale as well as the completion of project and presentation of poster. Average examination scores and self-evaluation scores were analyzed for trends. Learner feedback was collected concurrently with the final assessment. Average pre-test and self-evaluations scores were 3.29 &#xb1; 1.11 out of 7 and 11.0 &#xb1; 1.63 out of 20, respectively. Average post-test and self-evaluation scores increased dramatically to 5.71 &#xb1; 0.95 and 17.86 &#xb1; 1.77, demonstrating student acquisition of concepts and increased confidence in their knowledge of medical research. End-of-program scores were 6.43 &#xb1; 0.53 and 17 &#xb1; 1.15, respectively, and demonstrated good concept retention and retained confidence. The PRIMER model serves to both increase the capacity for resident-driven research in community hospital settings and provide pre-professional students with training and experience to help matriculate and succeed in medical programs. Resident physicians (PGY1-PGY4, n=15) indicated that the PRIMER program would be very helpful in designing (n=12), implementing (n=12), and completing (n=13) a research project. We were successful in implementing the program with three of four projects completed in the initial time frame planned. One project was not completed, and one contributing factor was resident vacation time. Future iterations in our program will consider the full resident schedule for the duration of the program. Research assistants feedback suggested improvements on coordinating resident schedules (vacation and graduation) with the program. We plan to implement the program two to three times each year to accommodate the overwhelming undergraduate interest and further enhance our residents' ability to ask clinically relevant research questions and explore those results in a community-based EM program. Medical research, statistics, data analysis, mentorship, data management, research ethics.

Poison centers (PCs) in Germany are medical facilities that serve as points of contact for cases of poisoning or suspected poisoning and are available by phone 24&#xa0;h a day. Consultations are provided by physicians who have completed specialized training in toxicology. Members of the public, healthcare professionals, and institutions with questions regarding toxicology can seek advice from the PCs. Over-the-counter medicines play an important role when contacting the PCs. These include pseudoephedrine (PSE), an indirect sympathomimetic, which is used in Germany as a combination preparation for the treatment of cold and flu symptoms and for the symptomatic treatment of allergic rhinitis. In Germany, PSE is combined with acetylsalicylic acid, acetaminophen, or ibuprofen, as well as with first- and second-generation H1 receptor antagonists. PSE has a decongestant effect on the mucous membranes of the nose and sinuses but also has stimulating effects and causes a feeling of alertness. This study includes an analysis of PSE poisoning cases reported to German PCs. They were asked to provide information on documented cases of PSE poisoning. Three of the seven centers surveyed provided their data (Erfurt 136 cases, G&#xf6;ttingen 175 cases, and Munich 210 cases, overall n&#x2009;=&#x2009;521). The individual cases were then analyzed in terms of various aspects. The patient cases analyzed revealed age-related differences, with a higher incidence in childhood, particularly among children under 6&#xa0;years of age. There were also indications of gender-specific differences. At the PC Erfurt, cardiovascular and neurological events predominate, with a male dominance. In Munich, neurological and gastrointestinal symptoms predominated. However, a high proportion of cases with unknown gender made gender-specific classification difficult. In Germany, young children up to the age of six are more severely affected despite contraindications and account for a significant proportion of inquiries to PCs. In recent years, PCs in Germany have reported an increase in cases of poisoning involving PSE combination preparations. A variety of symptoms have been observed in connection with PSE poisoning. As a preventive measure, it would be advisable for physicians-particularly pediatricians-and pharmacists to provide better patient education to raise awareness of the risks. Public platforms could also be used to conduct more educational outreach. Overall, the clinical relevance of PSE poisoning is evident from the present findings, which therefore require increased attention. PCs play an important role in this regard by providing acute consultation and systematically collecting data. However, the present findings should be interpreted in light of the limited data available to PCs.

Heart rate variability (HRV) has remained a relatively finite and niche tool in cardiology despite decades of research supporting its physiological and clinical relevance. This limited adoption may resemble the early history of electrocardiography (ECG), which was initially regarded by many physicians as a laboratory instrument rather than a routine clinical tool. The delayed acceptance of ECG reflected technological limitations, cultural resistance and the need for clinicians to master unfamiliar concepts derived from physics and electrophysiology. HRV faces comparable barriers today. Although derived from ECG RR intervals, HRV requires interpretation of time-domain, frequency-domain, geometric and nonlinear indices that may appear mathematically complex and distant from conventional bedside reasoning. We argue that HRV should not be viewed as a replacement for ECG, but as an extension of ECG from electrical morphology to physiological dynamics. Lessons from ECG history were examined and compared with the current state of HRV adoption in clinical practice. The complementary diagnostic roles of ECG morphology and HRV analysis were considered, together with the potential contribution of wearable sensors, remote monitoring, artificial intelligence and large language models to facilitate HRV interpretation, education and clinical integration. Whereas conventional ECG morphology identifies arrhythmias, conduction disturbances, ischemic alterations and overt electrical abnormalities, HRV provides insight into autonomic modulation, cardiovascular adaptability and systemic physiological regulation. The emergence of wearable sensors, remote monitoring, artificial intelligence and large language models creates an opportunity to overcome barriers that have limited HRV adoption. Artificial intelligence may serve as an educational and interpretive bridge, translating complex HRV metrics into clinically meaningful concepts while supporting medical training, artefact awareness, case-based learning and workflow integration. HRV faces barriers comparable to those encountered during the early adoption of ECG, including technological limitations, educational challenges and resistance to incorporating unfamiliar physiological concepts into routine clinical practice. Lessons from ECG history suggest that HRV adoption will depend not only on evidence but also on standardization, education, clinical interpretation and cultural acceptance within cardiology.

Given the constant pressure to improve patient experience, this study investigates how physicians' nonverbal communication (NVC) shapes patients' perceptions of service quality and patient satisfaction, while accounting for the role of gender in physician-patient interactions. To isolate the role of NVC, a 2&#x2009;&#xd7;&#x2009;2&#x2009;&#xd7;&#x2009;2 factorial design was employed, featuring manipulated kinesics (open vs. closed) and physician gender (male vs. female), with patient gender included as a measured factor. Data from 200 participants (50 per scenario) revealed that open kinesics significantly enhanced both service quality and patient satisfaction. Although physician gender alone had no direct impact, the interaction between physician and patient gender was significant for patient satisfaction. These findings emphasize the role of kinesic cues as a key dimension of NVC in shaping patient experience.

Access to specialized adult congenital heart disease (ACHD) care remains limited given workforce shortages and geographic concentration of accredited centers in urban regions. Southwest Florida lacked a board-certified ACHD specialist despite a growing population of adults with congenital heart disease. Patients frequently traveled long distances for subspecialty evaluation, contributing to delays in care, fragmented follow-up, and inequitable access to specialized services. A regional hub-and-spoke model was developed through collaboration between Lee Health and Memorial Healthcare System to expand access to ACHD expertise. The spoke site established a locally based ACHD clinic embedded within pediatric cardiology clinic and staffed by an advanced practice provider. ACHD physicians from the accredited hub center were credentialed within the local system and provided teleconsultation, telehealth support, weekly multidisciplinary conferences, and monthly onsite collaborative clinics. Geographic and workforce disparities remain major barriers to equitable ACHD care. Hub-and-spoke models can extend specialized ACHD expertise into underserved regions.

Pityriasis rosea is a self-limited inflammatory skin condition most commonly associated with systemic active viral infection, particularly human herpesvirus (HHV)-6 and HHV-7. Generally appearing as a herald patch, the rash subsequently spreads, commonly in a "Christmas tree" pattern on the back. There are atypical variants in which pityriasis rosea can present, making diagnosis challenging. This case is unique in that pityriasis rosea was misidentified, and it was only confirmed following histopathologic examination. Due to misidentification, there was an exacerbation of disease due to inappropriate treatment. A forty-year-old male on allopurinol for gout presented to the emergency department for 2-week history worsening rash on his abdomen and extremities. He was advised to discontinue allopurinol and was given oral corticosteroids for a suspected drug eruption. He followed up in an outpatient clinic 3 days later because the rash had worsened. At the outpatient clinic, he was suspected to have a viral exanthem; however, punch biopsy of the skin was taken and later confirmed the diagnosis of pityriasis rosea. Atypical presentations of pityriasis rosea can make diagnosis challenging, resulting in misidentification. Histopathology of inflammatory skin conditions can be used in the instances of diagnostic uncertainty. Reporting atypical cases of pityriasis rosea can raise awareness and aid physicians in identifying uncommon manifestations of the disease, which can potentially prevent unnecessary treatment and their adverse outcomes.

Electronic patient-reported outcome (PRO) monitoring has shown benefits in advanced cancer, but data specific to metastatic breast cancer (mBC) remain limited. Fatigue is a common, clinically important, and functionally impairing symptom in mBC, making it a patient-centered target for electronic PRO monitoring. To determine whether digital PRO monitoring with alert-based responses reduces fatigue in patients with mBC. This multicenter randomized clinical trial was conducted from May 2021 to February 2024, with 12 months of follow-up, at 52 breast cancer centers in Germany and included women aged 18 years or older with mBC who were receiving systemic therapy at any point in the metastatic disease course, had a life expectancy of longer than 3 months, were able to read German, and had smartphone access. Data analysis started in February 2024 and lasted 6 months. The intervention group completed weekly PRO questionnaires via a smartphone using validated short forms from the European Organization for Research and Treatment of Cancer computerized adaptive testing core item bank. Automated alerts based on predefined PRO deterioration were emailed to trained local nurses or physicians, who contacted patients by telephone within 48 hours. The control group received usual care with quarterly PRO questionnaires and no alerts. The primary outcome was fatigue at 6 months. Secondary outcomes included fatigue, physical functioning, and quality of life over 12 months. PROs were reported as standardized T scores. Of 2008 patients screened, 924 (46.0%) were randomized, and 909 (45.3%) were included in the primary analysis (median age, 50 years [range, 19-83 years]). Baseline mean (SD) fatigue T scores were 57.6 (9.5) in the intervention group and 60.2 (9.0) in the control group (P&#x2009;<&#x2009;.001), with baseline PROs assessed after randomization but before group-specific follow-up began. At 6 months, adjusted mean fatigue was 54.5 (95% CI, 53.7- 55.4) vs 59.9 (95% CI, 59.0-60.8), yielding a mean difference of -5.4 points (95% CI, -6.6 to -4.1; P&#x2009;<&#x2009;.001), exceeding the minimal clinically important difference (MCID) of 3.3 points. At 6 months, physical functioning was higher in the intervention group (mean difference, 4.0; 95% CI, 2.6-5.4), exceeding its MCID (3.2), whereas the between-group difference in quality of life was 0.8 points (95% CI, 0.02-1.5), which was less than the MCID of 2.9. This randomized clinical trial found that digital PRO monitoring was associated with clinically meaningful reductions in fatigue and improved physical functioning. These findings support further evaluation of alert-based PRO monitoring in routine oncology care. German Clinical Trials Register: DRKS00024015.

A 49-year-old male presented to the emergency department (ED) with bilateral knee pain that began after a mechanical fall down several steps. He states that he fell in such a way that both knees were flexed while he was in the air, which he described as a "flying prayer" position, and he landed with all his weight onto his flexed knees. He did not immediately seek medical care but instead wore knee braces and used crutches to ambulate. This resulted in multiple other falls due to persistent pain and lack of mobility. He was seen at an outside facility prior to presenting to our ED and was reportedly diagnosed with severe arthritis based on x-ray imaging and told he may have a minor quadriceps tendon injury. No other imaging was performed at that time. Due to continued pain, he presented to our ED where we utilized point-of-care ultrasound (POCUS) which revealed the presence of bilateral full-thickness quadricep muscle and tendon tears. He was treated with surgical repair of his quadriceps tendons and had an uncomplicated postoperative course. This case report highlights the importance of ultrasound in diagnosing musculoskeletal injuries and improving patient outcomes. We also summarize POCUS findings that emergency physicians can use to diagnose quadriceps muscle and tendon tears. Point-of-care ultrasound (POCUS), musculoskeletal ultrasound, tendon rupture, fall. Hines J, et al. A Case Report of Rare Bilateral Quadriceps Tendon Rupture Diagnosed by Point of Care.

The medical black bag is synonymous with physicians, especially general practitioners, who are expected to be ready to provide care across settings. The content of the devices they use will likely expand due to the proliferation of digital tools. As portable diagnostics diversify, guidance is increasingly needed on which tools clinicians should choose and what this shift may mean for the physical examination and point-of-care assessment. This study aimed to map the current, the possible, and the future content of the medical black bag using anticipatory methods, and to provide a general, practice-oriented outline of how portable diagnostic technologies may evolve in primary care. National equipment lists and the World Health Organization's MeDevIS database were compiled and filtered to define a contemporary reference set of reusable portable diagnostic instruments relevant to generalist practice. A 1-year trend analysis using major professional and medical technology news sources was conducted to identify possible additions, screening for devices with diagnostic relevance, portability, digital capability, market presence, and evidence visibility. To extend the outlook to the next decade, we performed a horizon-scanning exercise using the same review period. These devices were grouped into thematic categories. National equipment recommendations and World Health Organization lists yielded a stable core set of diagnostic tools used in routine primary care practice. Trend analysis and horizon scanning expanded this set by identifying possible and future additions of portable medical devices that can be used at the point of care. Overall, the identified technologies were increasingly digital, diverse, connected, and in some cases, AI-supported, reflecting a trajectory toward more integrated and data-enabled diagnostics. The medical black bag is likely to evolve from a stable set of familiar instruments toward a broader toolbox of portable and connected diagnostic devices. While these tools may expand the scope of bedside assessment and enable more reproducible and shareable clinical signs, their value depends on appropriate validation, usability, workflow integration, training, and supportive financial and organizational conditions. Regular evidence-informed updates of equipment recommendations, alongside practical implementation support, may help primary care systems adopt useful innovations while preserving the human dimensions of clinical care.

In January 2023, U.S. perinatal HIV guidelines shifted to support shared decision-making in infant feeding, ending categorical prohibition of breastfeeding for people living with HIV (PLHIV). This change did not reflect new safety evidence, low transmission risk and near-normal life expectancy with antiretroviral therapy has been established for over a decade, but the convergence of evidence with sustained ethical critique of the harms of prohibition. Three years later, uptake remains inconsistent: clinicians report uncertainty, and patient experiences suggest limited change in counseling or practice. We argue that eliminating prohibition of breastfeeding for PLHIV is fundamentally a de-implementation challenge. It calls for deconstruction of a practice that functioned not only as clinical guidance but as moral certainty, reinforced by legal and institutional structures. Standard implementation strategies were never designed for this task. Effective change requires deliberate unlearning of outdated assumptions at the individual and institutional level, healing between clinicians and communities whose trust was broken, and active dismantling of the legal, structural, and cultural infrastructure that encoded prohibition. We outline priorities, including structured unlearning activities, institutional reform, equity-centered training, privacy-protective research infrastructure, and advocacy for repeal of HIV criminalization statutes. The goal is to replace a paternalistic, physician-centered fiction of zero-risk with an allyship model where women's and infants' interests are maximally advanced in collaboration with their physicians, systems, and communities.

Clinicians are increasingly using emoji in digital communication, but limited qualitative work has examined how they assess the appropriateness, risks, and benefits of this practice. To characterize clinicians' reported utilization of and attitudes toward emoji in clinical messaging. Qualitative study using focus groups and a survey from August to October 2025. Twenty-nine clinicians at a large academic health system were recruited from 4 specialties and included physicians and advanced practice providers, genetic counselors, medical students, and other healthcare workers. Rapid qualitative analysis was used to identify both the benefits and drawbacks of emoji use in clinical messaging. Emoji were seen as clarifying tone, building rapport, softening directives, and reducing notification fatigue. However, participants also reported concerns about ambiguity, informality, and potential medicolegal risk due to messages' discoverability. Their assessment of appropriateness was context-dependent, including power hierarchies, personal familiarity, clinical gravity, generational differences, and the technical affordances of specific platforms. Emoji were viewed as more acceptable in informal contexts and among peers with whom they had established relationships, and as inappropriate in high-stakes and sensitive clinical contexts. Participants felt formal guidelines could be seen as condescending but suggested modifications to promote the clear and effective use of emoji in professional settings. Clinicians view emoji as useful but context-sensitive communication tools that should be used conscientiously. They disprefer universal, prescriptive guidelines. However, they promote explicit conversations about emoji use at onboarding and the modification of which emoji are available in local messaging platforms.